HomeMy WebLinkAbout- Septic Pumping Slip - 76 BOSTON HILL ROAD 5/13/2019 i furnliip�f r �
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ulo�ommonwealth of Massacbusetts,
City/Town of NORTH ANDOVER
System Pumping
Form 4 -/n
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DEP has provided this form for use by local Boards of Health., Other forms may be usedl but the
information rust substantially the same as that provided here. Before using this fora, check with! your
local Board ofHealth to determinethe form they use. The System Pumping in Record rust be submitted t
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the focal Board of'Health or,other approving authority within 14 days from the pumping date in
A, Facility Information
Important:When
filling out forms 1. System Location:
on the,
use only the tab, � 1 ILL RD,
key to move your Address
cursor-do not NORTH OVE 5
use the return
key .„ . S , . .... .....
pity. r
Y
2. Systems Owner,
r
KEVIN DUBS
Name
Address(if different from location)
City/Town State Zip Cade
Telephone Number
Bi. Pumping Record',
5/6/19 1500
I. Date of Pumping Date 2. Quantity Pumped„ Gallons
3. Component: Cesspool(s) Z Septic Ta `ight Tank El Grease s 'rap
E] Other(describe),
. Effluent Tee Filter present? 0, Yes EJ No If yes, was it cleaned? Yes, E] No
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5. Observed condition of component plumped:
GOOD
6. System, Pumped
By-
JAY CURRIER H794016
Name 'Vehic,le LicenseNumber
''S SEPTIC & DRAIN
Company
7. Location where nt nts were disposed,,,,
GLS
6 19
Sign r r Date
Signature f Receiving Facility r attach facility receipt Date
t5forrn , 1 1 12 System Pumping Record o Page 1 of